From all over India, wherever we went
on lecture tours or for participating in conferences or
seminars, there had been a suggestion from many different
friends and colleagues to write a book on “Recurrent
Miscarriages”. We shuddered at the thought of some student
somewhere in the country quoting us in this subject, be
given a discredit for his answer. This is not because the
answer would be wrong, but may not be agreeable to the
examiner. Therefore for nearly twenty years having worked in
this field we did not write any book on this subject.

However, over a period of time, there
was a constant influx of new treatment modalities and
understanding of this subject. Before 20 years when we began
our journey in this field much was hidden and very little
revealed. The usual approach to cases of miscarriages used
to be, give some HCG, give some progesterone, give some
aspirin and tie up the cervix. We now know that all of these
are never required in one subject and in many none at all
may be required. So beautiful is this phenomenon of early
pregnancy recognition and tolerance by the maternal system
that even an atheist would become a theist. At the same time
it is so intricate, so well organized and so profound that
even a theist would be converted into a die-hard atheist!

What we intend to do in these pages is
make an humble attempt on our part of showing the reader our
understanding of why pregnancy fails again and again in the
same mother. It is two years now that we started writing
this book and we are sure this may still not be the final
word after this long period.

We deeply acknowledge with profound
gratitude the support of our family members during this
stupendous task that ran into two years. We also thank Shri
Ramesh Kadam our typist and secretary who though not being a
medical person did his utmost to be flawless in his work. We
also thank the Dean of Medical College, Baroda, The
Superintendent S.S.G. Hospital Baroda and the Professor &
Head of our department for their blessings to this work.

We place this work at the feet of The
Lord – Almighty, at the service of humanity and mankind.

BARODA.
DR. Pankaj Desai
July 25, 2003.
DR. Purvi Patel

(ABSTRACTED FROM THE BOOK)

APPROACH TO A CASE OF RECURRENT MISCARRIAGE

Approach to the couple presenting with
recurrent pregnancy loss should be directed at finding an
etiological factor. A careful history directed at the fact
that were these proved pregnancies by a medical person or
just presumed pregnancies by the subject. It is also
important to know the timing of these abortions. Early
recurrent pregnancy losses are likely to be chromosomal.
Also it is now imperative to ask as to whether these were
missed abortions or live abortuses. The latter indicates an
anatomical cause.

Parental karyotyping will reveal those
couples with abnormal chromosome rearrangements. The
documentation of an abnormal parental karyotype warrants
prompt referral for genetic counseling for an accurate
assessment of the future risk of miscarriage. The outlook is
often not as bleak as anticipated by the couple and
karyotyping of the products of conception from any future
miscarriage is mandatory. Prenatal diagnosis in ongoing
pregnancies is recommended, as occasionally a pregnancy with
an unbalanced karyotype will progress to term, resulting in
the birth of an abnormal infant.

A detailed pelvic ultrasound will
identify the presence of PCOs and will also assess uterine
morphology. Uterine abnormalities detected on ultrasound can
be further investigated by hysteroscopy or
hysterosalpingography if necessary. As noted earlier, the
finding of a uterine anomaly does not necessarily imply
causation and surgical treatment may not be indicated.

An assessment of endogenous LH
secretion should be performed. A mid follicular serum LH
measurement may be elevated, but since LH is secreted in a
pulsatile manner from the pituitary gland, daily urinary LH
monitoring will be more informative. If hyper secretion of
LH is causally related to early pregnancy loss, suppression
of endogenous LH secretion should be an effective treatment
for this condition. There are some preliminary studies that
suggest this to be so. Johnson & Pearce compared the outcome
of pregnancy in an ovulatory women with PCO treated with
either clomiphene citrate or an LH releasing hormone
analogue to suppress pituitary secretion of LH followed by
gonadotrophin induction of ovulation. The latter treatment
was associated with reduced incidence of early pregnancy
loss compared to those pregnancies conceived with clomiphene.
Similarly women with PCOs undergoing IVF were more likely to
have an early miscarriage when super ovulation was achieved
with clomiphene and gonadotropins compared to treatment with
LH- releasing hormone analogue and gonadotrophins. However,
the tendency for clomiphene to increase basal LH secretion
may be contributing to the high early pregnancy loss rate in
the control groups of these studies.

Whether pituitary suppression of LH
offers an effective treatment in ovulatory women with raised
LH and recurrent early pregnancy loss has yet to be
determined. Other methods of suppressing LH include ovarian
diathermy, pre pregnancy treatment with progesterone and the
use of analogues to somatostatin, all of which await further
evaluation.
Autoimmune screening should include a search for both
anticardiolipin antibodies and lupus anticoagulant, as the
crossover between these types of APA is not complete. There
is no need to repeat APA testing in cases with moderate and
high positive titers. However, repeat testing may be
considered for subjects with low positive titers. There is
considerable inter-laboratory variation and standardized
techniques must be used for the detection of APA. Women with
both early and late miscarriages should be tested.

For those women with no documented
abnormality, supportive care, including serial
early-pregnancy ultrasonography, is valuable. Studies have
shown this type of therapy to improve the prognosis, with
the rate of live birth in the subsequent pregnancy up to
86%, although the outcome is age-related.